Combined Distal Interphalangeal Joint Arthrodesis With Proximal Interphalangeal Joint Arthroplasty or Arthrodesis: Technical Considerations.

Combined distal interphalangeal joint (DIP) arthrodesis with proximal interphalangeal joint (PIP) arthroplasty or arthrodesis presents unique challenges. Although less common than isolated surgery for the DIP and PIP joints, with an aging population, combined DIP and PIP procedures are an increasingly encountered occurrence. Anatomical and morphological studies have provided length and width measurement standards for the middle and distal phalanges, allowing for planning to assess the compatibility of strategies. Besides reviewing anatomical studies to provide length and width guidelines for hardware placement, we will also discuss optimal hardware combinations for combined surgical intervention in the DIP and PIP joints. Conflict may exist between hardware used for the DIP arthrodesis and implants used for the PIP arthroplasty. As an example, if K-wires are used for DIP arthrodesis, any intervention in the PIP joint will be compatible. However, if headless screws are used for DIP arthrodesis, these should ideally not reach proximal to the midpoint of the middle phalanx. Other techniques, such as single or multiple oblique screws, and tension bands are compatible with PIP arthroplasty. Hence, options for management of the PIP joint are dependent on the technique used for DIP arthrodesis.

Conventional High-Dose vs Low-Dose Hyaluronidase for Skin Necrosis after Hyaluronic Acid Fillers: A Systematic Review and Pilot Meta-Analysis.

BACKGROUND: Hyaluronidase remains the mainstay treatment for skin necrosis due to vascular occlusion after hyaluronic acid (HA) dermal fillers. There is wide variability in protocols for the administration of hyaluronidase. Most protocols, however, lack strong evidence regarding hyaluronidase dosages. METHODS: We conducted a systematic review and pilot meta-analysis, searching four international databases from inception until December 2023 for clinical studies reporting on two or more patients receiving hyaluronidase for skin necrosis after hyaluronic acid fillers. Random-effects (DerSimonian and Laird) meta-analyses were conducted. The primary outcome was the pooled proportion of complete scar resolution. We rated intra-study risk of bias using the Joanna Briggs Institute checklists and assessed the certainty of evidence using the GRADE approach. RESULTS: We included 15 studies totaling 223 patients. The pooled proportion of complete scar resolution after hyaluronidase administration was 77.8% (95%-CI: 65.5% to 86.6%, pegger = 0.093, low certainty). Patients treated with high doses of hyaluronidase (>500 international units [IUs]) had lower rates of resolution of 69.6% (95%-CI: 41.2% to 88.3%) compared to those treated with low doses (500IU or less) that had 88.1% rate of resolution (95%-CI: 86.0% to 96.2%), though not statistically significant (p= 0.18). The use of adjunct therapies did not have a statistically significant effect on outcomes. CONCLUSION: A higher proportion of patients receiving low doses (500IU or less) (88.1%) had complete scar resolution compared to patients receiving high doses (69.7%), though not statistically significant (p=0.18). Future studies should provide more granular details on their protocols to benefit the formulation of evidence-based guidelines in future. LEVEL OF EVIDENCE I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . PROTOCOL REGISTRATION: CRD42024538661.

Smartphone-Based DIY Home Microsurgical Training with 3D Printed Microvascular Clamps and Japanese Noodles.

We have recently incorporated simple modifications of the konjac flour noodle model to enable DIY home microsurgical training by (i) placing a smartphone on a mug to act as a microscope with at least ×3.5-5 magnification, and (ii) rather than cannulating with a 22G needle as described by others, we have found that cannulation with a 23G needle followed by a second pass with an 18G needle will create a lumen (approximately 0.83 mm) without an overly thick and unrealistic "vessel" wall. The current setup, however, did not allow realistic evaluation of anastomotic patency as the noodles became macerated after application of standard microvascular clamps, which also did not facilitate practice of back-wall anastomoses. In order to simulate the actual operative environment as much as possible, we introduced the use of 3D-printed microvascular clamps. These were modified from its previous iteration (suitable for use in silastic and chicken thigh vessels), and video recordings were submitted for internal validation by senior surgeons. A "wet" operative field where the konjac noodle lumen can be distended or collapsed, unlike other nonliving models, was noted by senior surgeons. With the 3D clamps, the noodle could now be flipped over for back-wall anastomosis and allowed patency testing upon completion as it did not become macerated, unlike that from clinical microvascular clamps. The perceived advantages of this model are numerous. Not only does it comply with the 3Rs of simulation-based training, but it can also reduce the associated costs of training by up to a hundred-fold or more when compared to a traditional rat course and potentially be extended to low-middle income countries without routine access to microsurgical training for capacity development. That it can be utilized remotely also bodes well with the current limitations on face-to-face training due to COVID restrictions and lockdowns.

Use of Micro Botulinum Toxin for a Face-lifting Effect: A Systematic Review.

BACKGROUND: Micro-Botox (Micro-btx) was described in 2000 for the paralysis of superficial muscle fibers to address facial rhytides. Increasingly, there are reports of its off-label use for a face-lifting effect. OBJECTIVE: To evaluate the literature for such results. METHODS AND METHODS: A systematic review was performed according to PRISMA; only Level ≥ III evidence from 2000 to 2020 were included. Data extracted include patient demographics, type of botulinum toxin, dilution, dosage, injection sites and spacing, needle size and syringe, follow-up, patient and physician assessment, and complications. RESULTS: Three hundred seventy-two patients (average 35.2 years) underwent different botulinum toxin injections (average 39 units/hemiface) of varying dilutions with 30- to 32-G needles, typically with 1-mL syringes, by forming 0.2- to 0.5-cm wheals 1 cm apart. Follow-up averaged 10.5 weeks with both subjective and objective assessments. Facial asymmetry and minor bruising were common. Subjective assessment of face-lifting effects between patients and physicians was highly discordant and injection sites reported were highly variable. CONCLUSION: Much heterogeneity in dosage, injection sites, definition of "face-lifting," and assessment methods remain, all of which preclude accurate and objective evaluation of the current evidence for micro-btx. Future studies should address these variables, given the growing interest in such nonsurgical options for a face-lifting effect.

The Perception of Plastic Surgery by Community-Based, Private Practice Nurses: A French National Descriptive Study.

Plastic surgery is a dynamic field but remains poorly understood by general practitioners, medical students, health professionals, and the public. The main health care professionals in the community who are involved in the follow-up of plastic surgery patients are nurses; they help to facilitate wound healing and rehabilitation in the postoperative period. In this study, the authors assessed the medical knowledge and perceptions of plastic surgery by nurses working in the community setting and explored their understanding of classical scenarios commonly encountered in reconstructive surgery. An online survey was designed to assess the demographics of nurses working in the community in France and their knowledge of plastic surgery. This was disseminated to all practicing nurses working outside of hospitals by means of an online social network from the period of April 2019 to June 2019. The survey was completed by 318 nurses. Specific training in plastic surgical nursing will be required to optimize the management of these patients following discharge from hospital. This gap in knowledge may affect patient recovery negatively.

Graft vasculopathy of vascularized composite allografts in humans: a literature review and retrospective study.

Mechanisms of chronic rejection of vascularized composite allografts (VCA) remain poorly understood and likely present along a spectrum of highly varied clinicopathological findings. Across both animal and human VCA however, graft vasculopathy (GV) has been the most consistent pathological finding resulting clinically in irreversible allograft dysfunction and eventual loss. A literature review of all reported clinical VCA cases with documented GV up to December 2018 was thus performed to elucidate the possible mechanisms involved. Relevant data extracted include C4d deposition, donor-specific antibody (DSA) formation, extent of human leukocyte antigen (HLA) mismatch, pretransplant panel reactive antibody levels, induction and maintenance immunosuppression used, the number of preceding acute rejection episodes, and time to histological confirmation of GV. Approximately 6% (13 of 205) of all VCA patients reported to date developed GV at a mean of 6 years post-transplantation. 46% of these patients have either lost or had their VCAs removed. Neither C4d nor DSA alone was predictive of GV development; however, when both are present, VCA loss appears inevitable due to progressive GV. Of utmost concern, GV in VCA does not appear to be abrogated by currently available immunosuppressive treatment and is essentially irreversible by the time of diagnosis with allograft loss a likely eventuality.

Penis Transplantation: First US Experience.

OBJECTIVE: We describe the first successful penis transplant in the United States in a patient with a history of subtotal penectomy for penile cancer. BACKGROUND: Penis transplantation represents a new paradigm in restoring anatomic appearance, urine conduit, and sexual function after genitourinary tissue loss. To date, only 2 penis transplants have been performed worldwide. METHODS: After institutional review board approval, extensive medical, surgical, and radiological evaluations of the patient were performed. His candidacy was reviewed by a multidisciplinary team of surgeons, physicians, psychiatrists, social workers, and nurse coordinators. After appropriate donor identification and recipient induction with antithymocyte globulin, allograft procurement and recipient preparation took place concurrently. Anastomoses of the urethra, corpora, cavernosal and dorsal arteries, dorsal vein, and dorsal nerves were performed, and also inclusion of a donor skin pedicle as the composite allograft. Maintenance immunosuppression consisted of mycophenolate mofetil, tacrolimus, and methylprednisolone. RESULTS: Intraoperative, the allograft had excellent capillary refill and strong Doppler signals after revascularization. Operative reinterventions on postoperative days (PODs) 2 and 13 were required for hematoma evacuation and skin eschar debridement. At 3 weeks, no anastomotic leaks were detected on urethrogram, and the catheter was removed. Steroid resistant-rejection developed on POD 28 (Banff I), progressed by POD 32 (Banff III), and required a repeat course of methylprednisolone and antithymocyte globulin. At 7 months, the patient has recovered partial sensation of the penile shaft and has spontaneous penile tumescence. Our patient reports increased overall health satisfaction, dramatic improvement of self-image, and optimism for the future. CONCLUSIONS: We have shown that it is feasible to perform penile transplantation with excellent results. Furthermore, this experience demonstrates that penile transplantation can be successfully performed with conventional immunosuppression. We propose that our successful penile transplantation pilot experience represents a proof of concept for an evolution in reconstructive transplantation.

One-Stage Supramaximal Full-Thickness Wedge Resection of Vascular Lip Anomalies.

PURPOSE: Vascular lip anomalies include infantile hemangiomas, venous malformations, and arteriovenous malformations. Surgical management can be complicated by alterations in horizontal length, vertical height, and lip thickness from the underlying pathology. Additional reconstructive challenges include preservation of oral continence, vermillion definition, and the sublabial sulcus. This report describes a technique of supramaximal single-stage full-thickness wedge resection of these lesions. MATERIALS AND METHODS: A retrospective study approved by the institutional review board of patients who underwent full-thickness resection of vascular lip anomalies from December 2007 through February 2013 was performed. Patient demographics, final diagnosis, preoperative treatment, examination findings (pre- and postoperative), intraoperative management, and follow-up findings were reviewed. RESULTS: Eighteen patients (9 female) with a mean age of 25 ± 19.8 years (range, 3 to 70 yr) were identified. Underlying pathologies were arteriovenous malformation (6), port wine stain with secondary soft tissue hypertrophy (6), capillary malformation (1), venous malformation (3), and infantile hemangioma (2). Prior treatments included embolization, lasers, surgical excision, steroids, and propranolol; 8 patients were treatment naive. All patients underwent a single or double pentagonal-shaped wedge resection of the involved upper or lower lip. An average of 3.75 cm (41.7%; range, 20 to 70%) of horizontal lip length was excised. Four patients required additional concomitant debulking of the vermillion. No intraoperative complications were noted. Postoperatively, 1 patient developed wound dehiscence at 12 days and another had a midline depression with mild oral incontinence. Follow-up averaged 1,074 days (range, 371 to 1,777 days) and patients and their parents reported a high degree of satisfaction with the improvement in lip appearance and symmetry except for 1 patient who required further debulking. The sublabial sulcus and vermillion and cutaneous definition were preserved in all cases. CONCLUSION: Despite the traditional recommendation that no more than 30% of lip length be surgically removed, vascular lip anomalies result in tissue hypertrophy, horizontal elongation, ectropion labii, and tissue expansion that allow up to 70% of the lip to be excised.

Reconstruction of Pediatric Scalp Avulsion Injuries After Dog Bites.

Dog bite injuries are common and the head and neck is most frequently involved in pediatric patients. In severe cases, the combination of crushing, tearing, and puncturing can result in scalp avulsion. Currently, microsurgical replantation of the avulsed scalp remains the gold standard but may not always be possible. The authors present their treatment algorithm with 2 patient examples. In Patient 1, the scalp was deemed unsuitable for replantation due to extensive soft tissue injury; in Patient 2, the scalp was not available on presentation. Both patients underwent debridement and early wound coverage followed by multistage secondary revision through serial tissue expansion and excision. At 3-years follow-up, both patients have achieved satisfactory aesthetic outcomes following the initial loss of 70% and 40% of hair-bearing scalp. There were no infective complications or wound dehiscence and the areas of scar alopecia are much improved with preservation of the hairline. Pediatric scalp avulsion injuries resulting from dog bites are uncommon and involve a unique injury mechanism. Coupled with the diminutive size of vessels in this patient population, replantation may be precluded altogether. A delayed and staged approach to reconstruction can restore a hair-bearing scalp for satisfactory outcomes.

Efficacy of Topical Timolol as Primary Monotherapy in Cutaneous Facial Infantile Hemangiomas.

Recent studies have shown that infantile hemangiomas (IHs) undergo a rapid growth phase between 5.5 and 7.5 weeks of life and do not usually proliferate beyond 6 months; growth thereafter is usually proportionate to the child's growth. This review assesses the evidence for topical timolol as primary monotherapy for cutaneous facial IHs before 12 months of age, and to determine the differences in outcome between early (before 6 months) and late initiation (after 6 months) of timolol. A review of English language articles published up to November 2015 was performed using selected key words. Articles identified were further reviewed for relevance. The full text of studies included for final analysis was perused to include pertinent patient details, treatment protocol with timolol, complications (if any) reported, and response to treatment. Four studies met the inclusion criteria. In children before 12 months of age, the efficacy of topical timolol for the treatment of cutaneous facial IHs in achieving clinically significant improvement as defined by a standardized Global Assessment Score score of 3 and above ranged from 47% to 88%. One study also showed that IH regression was greater in patients started on timolol before 6 months of age compared with those started later (P <0.05). Topical timolol initiated in children before 12 months of age appears to be safe and clinically effective. There was insufficient data for detailed analysis of outcomes in patients who commenced treatment before and after 6 months of age.

Discordant Type I Preaxial Polydactyly in Monozygotic Twins on the Same Hand: A Case Report.

There are 4 types of preaxial polydactyly (PPD), and type I (PPD-I), also known as thumb duplication, is the most common. This frequently encountered condition has since been further described and classified by Wassel based on the level of duplication of skeletal anatomy. Genetic studies have localized possible candidate gene(s) for PPD types II to IV to the chromosomal region 7q36 but the current literature attributes PPD-I to isolated, spontaneous mutations typically with unilateral involvement only. Recent epidemiological studies have also suggested nongenetic causes for PPD-I including social and environmental factors. Herein, we would like to present a case of discordant PPD-I expression affecting the same hand in a pair of monozygotic twins and suggest possible reasons for this presentation because previous similar reports only had involvement of 1 child.

Results of Primary Repair of Submucous Cleft Palate With Furlow Palatoplasty in Both Syndromic and Nonsyndromic Children.

OBJECTIVE: We hypothesize that primary repair of submucous cleft palate (SMCP) with Furlow palatoplasty will not lead to significant differences in speech outcomes for syndromic and nonsyndromic children. DESIGN: Retrospective analysis of patients with primary Furlow repair of SMCP between 2004 and 2012. SETTING: Tertiary care center. PATIENTS/PARTICIPANTS: Thirty-four patients (15 boys; 44%) satisfied our inclusion criteria: multidisciplinary consensus on diagnosis of SMCP, failed trial of speech-language rehabilitation, at least 4 years old at the time of primary surgery, at least 6 months follow-up with a repeat set of postoperative speech assessments. INTERVENTIONS: Primary Furlow palatoplasty for SMCP. MAIN OUTCOME MEASURES: Primary outcomes were based on postoperative perceptual speech assessments and the need for revision surgery. Secondary outcomes included improvement in nasalance scores, postoperative complications, and change in and time to normalization of velar closing ratios. RESULTS: Mean age at surgery = 7.7 years. Of the patients, 17 (50%) were syndromic and 11 (32%) had associated hearing loss. Mean follow-up = 48 months. No patients had postoperative complications, such as wound dehiscence or fistula; however, two patients (one syndromic, one nonsyndromic) required secondary procedures. Velar closing ratios for all patients increased (P < .05) and approached normal at an average of 1.3 years postoperatively. CONCLUSIONS: Although the Furlow palatoplasty can correct anatomic anomalies, it cannot achieve normal perceptual resonance in syndromic patients, possibly because of inherent higher-order deficiencies that affect speech production. Further studies with greater patient numbers are necessary to achieve population statistical significance.

Computer-designed PEEK implants: a peek into the future of cranioplasty?

BACKGROUND: Polyetheretherketone (PEEK) is a synthetic material that was used initially in spine and hip surgery. It has the properties of being biocompatible, resistant to thermal and ionizing radiation, and resembles cortical bone biomechanically. These favorable characteristics have led to the increasing use of PEEK implants for calvarial defects which remain a significant reconstructive challenge. METHODS: This study is a retrospective review of patients who underwent PEEK cranioplasty by a single surgeon. PEEK implants were fashioned from high-resolution CT scans of each patient and sterilized preoperatively before cranioplasty was performed using standard techniques. The mean follow-up period was 7 months (range 1-22). RESULTS: Twelve consecutive patients (75% males; mean age = 43, range 16-67) underwent PEEK cranioplasty between January 2011 and December 2012 after a mean time interval of 10 months (range 3-40) following initial craniectomy. The mean defect size was 11 × 8 cm (range 7 × 6 to 14 × 8 cm) and no additional contouring of PEEK implants was necessary intraoperatively. The scalp was closed primarily in all patients, and no complications of implant breakdown, wound infection, or cerebrospinal fluid leak were appreciated during follow-up. CONCLUSIONS: Computer-designed, patient-specific PEEK implants for cranioplasties are a viable alternative when autologous bone grafts are unavailable or unsuitable. Such prefabrication reduces operative times through minimal to no intraoperative adjustments. Although initial results are promising, longer-term follow-up and further comparative studies including randomized control trials to evaluate outcomes between different alloplastic materials for cranioplasty are necessary.

Computer-designed polyetheretherketone implants versus titanium mesh (± acrylic cement) in alloplastic cranioplasty: a retrospective single-surgeon, single-center study.

BACKGROUND: Polyetheretherketone (PEEK) has emerged as one of the most promising alloplastic materials for calvarial reconstruction because of a number of desirable qualities including resistance to heat and ionizing radiation, biocompatibility, biomechanically similar to native bone, and being nonferromagnetic for postoperative monitoring. We aimed to evaluate and compare the outcomes of alloplastic cranioplasty performed with PEEK, titanium mesh only (Ti-only), and titanium mesh with acrylic cement (Ti-AC); titanium mesh has previously recorded many successes with low complication rates. METHODS: A retrospective, single-surgeon, single-center study for alloplastic cranioplasties was performed between January 2008 and December 2012. Titanium meshes were fashioned intraoperatively, whereas PEEK implants were prefabricated from high-resolution computed tomography scans. Patients were routinely followed up in outpatient settings. RESULTS: Twenty-four patients (75% male) underwent delayed cranioplasty following initial craniectomy. Four Ti-only and 3 Ti-AC patients had postoperative complications including wound breakdown and implant exposure. These assumed a bimodal distribution with time postoperatively and culminated in implant removal in 6 patients, of which 4 required further plastic flap coverage. Subgroup analysis showed no significant differences in predictive factors apart from cranioplasty material with means as follows: age = 42 years, interval to surgery = 10 months, defect size = 12 × 9 cm, operation duration = 181 minutes, hospital stay = 13 days, follow-up = 11 months. CONCLUSIONS: Early results suggest that PEEK may be superior to Ti-only or Ti-AC as an alloplastic cranioplasty choice. Further research should include randomized trials between computer-aided, prefabricated titanium and PEEK cranioplasties with larger sample sizes and longer follow-up.

Resolution of concomitant Achromobacter xylosoxidans burn wound infection without adjustment of antimicrobial therapy.

Achromobacter xylosoxidans is part of an emerging group of Gram negative bacterial infections with potentially severe sequelae, especially in the immunocompromised population such as burn patients. While antimicrobial therapy for patients with A. xylosoxidans bacteremia has been reported, the literature is scarce with regard to treatment in patients with positive tissue cultures only. Herein, we report our institution's experience with such a case and a brief review of the current literature on this micro-organism in the setting of non-bacteremic infection.

UK Trainee Experience with WALANT - An Audit of 102 Cases.

Background: WALANT has gained much popularity in recent years, especially with COVID-19. However, a recent survey of the American Society for Surgery of the Hand membership (i.e. attendings/consultants) showed that only 17% were exposed to WALANT during residency or fellowship training. There is much interest in WALANT from trainees, but interpretation of the type and volume to be administered is highly varied. Methods: The aims of this study were (1) to survey a group of plastic surgery trainees in the UK about their knowledge of WALANT formulas, and (2) to compare trainee logbook records of WALANT procedures (if available) with published data from the UK. Results: All trainees were familiar with the 'standard' WALANT formula (1% lidocaine, 1:100,000 adrenaline ± 8.4% NaHCO3) described by Lalonde. However, because of local formularies, rather than 1:100,000 adrenaline, all used 1:200,000 adrenaline as it comes premixed in the UK. Other formulas used by UK trainees included 0.5% bupivacaine + 1:200,000 adrenaline, and mixing 1% lidocaine + 1:200,000 adrenaline with 1% lidocaine 1:1. In comparing available trainee WALANT records with published UK data, the average volume of WALANT used was 6.6 mls in the current study versus 12.9 mls for similar procedures (wound debridement and skin closure ± local flap, digital nerve repair, fingertip reconstruction, thenar injuries, phalangeal fracture and single digit extensor repair); specifically, for single digit flexor tendon repairs, this was 10 mls versus 16.3 mls. Conclusions: While the British Society for Surgery of the Hand (BSSH) have developed official guidance for the use of WALANT in the UK, it appears there remains much variation in interpretation and hence, application. Comparison of trainee logbook records of common hand surgery procedures suggests that most can be done with much less WALANT administered than previously reported, with safe and reproducible results. Level of Evidence: Level IV (Therapeutic).